Form Ssa-2490-Bk - Application For Benefits Form Page 5
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7(a) During the past 24 months, did the worker engage in employment or
15.
Yes
No
self-employment covered by the U.S. Social Security system?
(If "Yes" answer
(If "No" go on
(b) and (c) below.)
to item 16.)
List the periods of work covered by the U.S. Social Security system and the name and address of the
employer or self-employment activity
(b) Name and address of employer or self-employment
Work Began
Work Ended
activity
(Month-Year)
(Month-Year)
(c) May we ask any employer listed above for wage information needed
Yes
No
to process this claim?
INFORMATION ABOUT DEPENDENTS FOR WHOM BENEFITS ARE CLAIMED
(a) Are there any children of the worker who are now, or were
16.
Under age 18
Yes
No
in the past 12 months, unmarried and:
OR
Age 18 or over and a
Yes
No
student or disabled
If either block is checked "Yes", enter the information for each child. NOTE: Children include natural children,
step-children and adopted children plus grandchildren living in the same household as the worker.
(c) Relationship to
(d) Sex
(e) Date of birth
(b) Name of child
worker
(M or F)
(Month, day, year)
The spouse, widow or widower of the worker may be eligible for a benefit. In addition, a former spouse of
17.
the worker may be eligible as a divorced spouse, widow or widower. Provide the following information about
any spouse or former spouse of the worker.
SPOUSE
FORMER SPOUSE
FORMER SPOUSE
(a) Name (including
maiden name)
(b) Date of Birth
(Mo., day, yr.)
(c) Date of Marriage
(Mo., day, yr.)
(d) Date of Divorce
(if any)
(Mo., day, yr.)
(e) Country of
Citizenship
(f) Social Insurance
Number in
foreign country
(g) U. S. Social
Security Number
(if any)
Form SSA-2490-BK (4-2004)
EF (4-2004)
Page 5
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